Resuscitation, Neonate, Emergency Medicine

Basics

Description

Annually, almost 1 million deaths worldwide are related to birth asphyxia.
10% of newborns require some assistance at birth.
1% of newborns require extensive resuscitation.
Consider NOT initiating resuscitation if:
- Newborns confirmed to be <23-wk gestation or 400 g
- Anencephaly
- Babies with confirmed trisomy 13 or 18
- Ideally, discuss with family and health care team prior to delivery.
Activity, pulse, grimace, appearance, respiration (APGAR) scores do not guide resuscitation:
- Do not wait to assign APGAR scores before starting resuscitation.
- APGAR scores should NOT guide resuscitative efforts. It is a measure of an infants status and response to resuscitation.
- APGAR score: 5 categories with score of 0, 1, or 2 in each at 1 and 5 min
Heart rate (HR): 0 = absent; 1 = <100 bpm; 2 = >100 bpm
Respirations: 0 = absent; 1 = slow, irregular; 2 = good, crying
Muscle tone: 0 = limp; 1 = some flexion; 2 = active motion
Reflex irritability: 0 = no response; 1 = grimace; 2 = cough, sneeze, cry
Color: 0 = blue or pale; 1 = pink body and blue extremities; 2 = all pink

Etiology

Newborns transition from dependence on the placenta to dependence on the lungs for oxygen.
Hypoxia initially causes tachypnea followed by primary apnea.
Stimulation may cause resumption of breathing during primary apnea.
Continued hypoxia leads to secondary apnea.
Secondary apnea requires assisted ventilation.
Antepartum risk factors associated with need for resuscitation include:
- Maternal diabetes
- Pregnancy-induced hypertension
- Chronic hypertension
- Anemia
- Previous fetal or neonatal death
- Bleeding in 2nd or 3rd trimester
- Maternal infection
- Maternal cardiac, renal pulmonary, thyroid or neurologic disease
- Polyhydramnios
- Oligohydramnios
- Premature rupture of membranes
- Post-term gestation
- Multiple gestation
- Size " ôdates discrepancy
- Drug therapy
- Maternal substance abuse
- Fetal malformation
- Diminished fetal activity
- No prenatal care
- Maternal age <16 yr or >35 yr
Intrapartum risk factors associated with need for resuscitation include:
- Emergency C-section
- Forceps or vacuum assist
- Breech or other abnormal presentation
- Premature labor
- Precipitous labor
- Chorioamnionitis
- Prolonged rupture of membranes
- Prolonged 2nd stage of labor
- Fetal bradycardia
- Nonreassuring fetal heart tracing
- General anesthesia
- Uterine tetany
Narcotics administered to mother within 4 hr:
- Meconium-stained amniotic fluid
- Prolapsed cord
- Abruptio placenta
- Placenta previa

Diagnosis

Signs and Symptoms

Compromised infants requiring resuscitation may exhibit 1 or more of: é á

Decreased muscle tone
Depressed respiratory drive
Bradycardia
Hypotension
Tachypnea
Cyanosis

History
Risk factors as above predict the need for resuscitation é á
Physical Exam

Respirations " örate and effectiveness
HR " öby auscultation or palpation of umbilical cord
Color

Essential Workup

ABCs: é á

Airway
Breathing
Circulation
Drying and warming child

Diagnosis Tests & Interpretation

Lab

Bedside blood glucose measurement
Blood gas

Imaging
Chest radiograph é á
Diagnostic Procedures/Surgery

Endotracheal intubation:
- Straight blades Miller 1 for full term, Miller 0 for preterm
- Endotracheal tubes (ETTs):
  - 2.5 for <1,000 g or <28 wk
  - 3 for 1,000 " ô2,000 g or 28 " ô34 wk
  - 3.5 for 2,000 " ô3,000 g or 34 " ô38 wk
  - 4 for >3,000 g or >38 wk
- Have stylet, end-tidal CO2 detector, suction, tape, meconium aspirator available.
Umbilical vein catheterization:
- Tie umbilical tape around base of cord.
- Prefill syringe attached to umbilical catheter (3.5 or 5F).
- Cut cord on clean edge below clamp.
- Identify umbilical vein (large, thin walled, and single).
- Insert catheter into umbilical vein directed cephalad.
- Advance 2 " ô4 cm until blood flows freely into syringe.
- Check position with plain film.
- Inject drugs/fluids as appropriate.

Treatment

Pre-Hospital

Resuscitation should be started by pre-hospital personnel.
Neonatal resuscitation equipment should be available. Anticipation and preparation required.
Pay particular attention to heat retention and warming.

Initial Stabilization/Therapy

ABCs
Provide warmth, clear airway, stimulate
If meconium, poor respiratory effort, poor muscle tone, cyanosis, or prematurity are present, proceed with resuscitation.
Initial steps include:
- Warm the baby.
- Position (neck slightly extended, sniffing position) and clear the airway (meconium may necessitate intubation " ösee below).
- Dry thoroughly; stimulate (flick feet, rub trunk or extremities).
- Provide oxygen:
  - In term infant, room air resuscitation may be advantageous to avoid hyperoxia.
  - In premature infants, blended oxygen with close monitoring of oximetry is appropriate.
Meconium:
- Meconium present and baby is NOT vigorous:
  - Insert ETT.
  - Suction with ETT meconium aspiration device.
  - Slowly withdraw tube.
  - Repeat as necessary until little meconium is recovered or HR is maintained.
- Meconium present and baby is vigorous:
  - Suction mouth then nose with bulb or suction catheter.
If re-evaluation within 30 sec reveals apnea or HR <100 bpm, proceed with:
- Positive-pressure ventilation with 100% oxygen
- Self-inflating or flow-inflating (anesthesia type) bag
- Proper-fitting mask
- 1st breath may require high pressure, necessitating occlusion of "pop-off " Ł valve.
- Rate of 40 " ô60 breaths/min
- Pressure of 30 " ô40 cm H2O
- If prolonged, place nasogastric (NG) tube.
If re-evaluation after 30 sec of positive-pressure ventilation with 100% oxygen reveals HR <60 bpm, proceed with:
- Continued positive-pressure ventilation and chest compressions
- 2-thumb technique: Hands encircle torso
- 2-finger technique:
  - Compress ó ł ╝1/3 of the anterior " ôposterior diameter of chest and release.
3 compressions followed by 1 ventilation
120 events/min (90 compressions and 30 breaths)
If after 30 sec HR is >60 bpm, stop compressions.
If after 30 sec HR is >100 bpm, stop positive-pressure ventilator.
If after 30 sec HR still <60 bpm, administer epinephrine (IV or via ET tube).

Ed Treatment/Procedures

If evidence of blood loss or poor response to resuscitation, administer volume expander.
NS, lactated Ringer, O-negative blood (cross-matched if time permitting)
If severe metabolic acidosis is suspected or proven:
- Ensure adequate ventilation.
- Administer sodium bicarbonate.
If hypoglycemia is proven or suspected, treat with IV dextrose.
If HR and color improve but respiratory effort and tone are poor and mother received narcotics within 4 hr, treat with naloxone hydrochloride:
- Contraindicated in mothers addicted to narcotics or receiving methadone: Can precipitate seizures.
Persistent distress may indicate pneumothorax.
Known or suspected diaphragmatic hernias should be treated with immediate endotracheal intubation and placement of NG tube.
Consider discontinuation of resuscitation if 10 min of asystole.

Medication

Dextrose: 2 " ô4 mL/kg of D10W given IV (umbilical vein)
Epinephrine: 0.1 " ô0.3 mL/kg of 1:10,000 solution, may be given IV or via ETT (0.3 " ô1 mL/kg if giving via ETT)
Naloxone hydrochloride: 0.1 mg/kg. Administer IV or via ETT; can administer IM or SC, but onset of action is delayed.
Sodium bicarbonate: 2 mEq/kg (4 mL/kg of 4.2% solution) (0.5 mEq/mL). Administer slowly via IV route (umbilical vein).
Volume expanders: NS, lactated Ringer, blood. Initial dose 10 mL/kg, may be repeated, all given IV (umbilical vein).
Other agents as specifically indicated by newborns underlying condition

Follow-Up

Disposition

Admission Criteria

All newborns require admission.
If significant resuscitation is necessary, admit to NCIU.

Pearls and Pitfalls

Resuscitation and care of low-birth-weight infants may lead to the following complications:
- Difficulty with thermoregulation
- Intraventricular hemorrhage
- Chronic lung disease
- Retinopathy of prematurity
Oxygen and the very low-birth-weight (VLBW) infant:
- VLBW infant defined as birth weight <1,500 g
- VLBW infants are at increased risk of oxidative stress and damage including retinopathy of prematurity.
- Some studies suggest resuscitating with <100% oxygen in this group, possibly even 21% (room air), to avoid oxidative stress and damage.

Additional Reading

Fowlie é áPW, McGuire é áW. Immediate care of the preterm infant. BMJ. 2004;329(7470):845 " ô848.
Kattwinkel é áJ, ed. Textbook of neonatal resuscitation. 5th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006.
Kattwinkel é áJ, Perlman é áJM, Aziz é áK, et al. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S909 " ôS919.
Kubicka é áZJ, Limauro é áJ, Darnall, é áRA. Heated, humidified high-flow nasal cannula therapy: Yet another way to deliver continuous positive airway pressure? Pediatrics. 2008;121:82 " ô88.
Vaucher é áYE, Peralta-Carcelen é áM, Finer é áNN, et al. Neurodevelopmental outcome in the early CPAP and pulse oximetry trial. N Engl J Med. 2012;36:2495 " ô2504.

Codes

ICD9

768.5 Severe birth asphyxia
768.6 Mild or moderate birth asphyxia
768.9 Unspecified severity of birth asphyxia in liveborn infant

ICD10

P84 Other problems with newborn é á

SNOMED

28314004 asphyxia, in liveborn infant (disorder)
77362009 mild to moderate birth asphyxia (disorder)
57284007 severe birth asphyxia (disorder)

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